Laparoscopic Partial Splenectomy by Transient Clamping of the Splenic Artery as a Promising Technique

Highlights

What are the main findings?

• Temporary main splenic artery occlusion during laparoscopic splenectomy reduces blood loss.
• This simple technique could be advised in cases of partial splenectomy.

What are the implication of the main findings?

• Temporary splenic artery clamping may improve surgical safety by minimizing bleeding.
• This technique could be recommended as useful adjunct in partial splenectomy cases.

Abstract

Background: Laparoscopic partial splenectomy (LPS) is a technically demanding procedure. The main difficulty when considering LPS is the bleeding risk. With advancements in technology and a deeper understanding of spleen vascular distribution, LPS has emerged as a feasible and safe procedure. Methods: There are many techniques used in order to prevent bleeding; in our case, we performed LPS using transient main splenic artery clamping. Our case represents a 65-year-old man who was diagnosed with a space-occupying lesion in the lower pole of the spleen and underwent LPS by temporary non-selective occlusion of the splenic artery. Results: The LPS was successfully performed. The surgery length was about 105 min, and it took about 48 min from placement of the bulldog on the splenic artery (warm ischemia), transecting the splenic parenchyma and release of the bulldog. The estimated blood loss was less than 50 mL. The recovery was smooth and uneventful, and the patient was discharged on the third postoperative day. Conclusions: LPS with temporary occlusion of the main trunk of splenic artery is shown to be an effective, practicable and reliable method that is associated with minor operative blood loss.

1. Introduction

Laparoscopic partial splenectomy (LPS) is an effective and safe procedure, which is considered nowadays as a safe surgical procedure for some lesions that affect the spleen.

The main objective of spleen preservation is to preserve splenic function, which plays a crucial role in the immune system and in reducing postoperative complications compared to total splenectomy [1].

Partial splenectomy (PS) can be considered for idiopathic splenomegaly, splenic cysts, benign lesions, isolated splenic metastases, splenic infarction, iatrogenic or traumatic splenic injuries, and hematological disorders like hereditary spherocytosis [2,3,4,5,6].

PS can be performed through different techniques, including laparoscopic, single-port, and robotic approaches [7,8,9,10]. In most of the reported cases, LPS was performed through selective occlusion of the superior or inferior terminal branch of the splenic pedicle after its identification [7,8,9,10,11]. Only some reported cases performed LPS through non-selective occlusion of the main splenic artery, followed by closure of the upper or lower polar branch. Also, the three-block technique with occlusion of the main artery with pedicle occlusion was described and showed promising results [7]. However, this technique is difficult to acquire and challenging, especially for large lesions or centrally located lesions. The difficulty of these techniques mainly derives from the need for dissection around the small splenic polar vessel at the splenic hilum. The non-selective occlusion is simpler, which could accelerate its wide adoption and reduce the learning curve.

In our cases, we performed LPS through transient clamping of the splenic trunk without the need to clamp the upper or lower branches.

We believe that our technique is less challenging and may reduce operating time, as there is no need for vascular dissection beyond the main splenic artery, which could reduce the amount of intraoperative bleeding.

2. Case Report

A 65-year-old man with past medical history of hypertension and osteoporosis underwent laparoscopic single anastomosis gastric-bypass in 2021 because of morbid obesity.

The patient was directed to our center for further investigation and intervention due to a splenic mass that was detected by abdominal ultrasound (US) and computer tomography (CT) scan, which was performed at an outpatient clinic as part of an abdominal pain investigation.

Abdominal radiologic evaluation revealed a 4.2 cm nodule in the lower pole of the spleen. Positron Emission tomography (PET-CT) identified suspicious uptake of Fluro-Deoxy-Glucose (FDG) in a 3 cm splenic nodule.

After tumor board discussion for the risk and benefit of biopsy, and because of the unknown nature of the tumor, the patient underwent CT-guided percutaneous biopsy, which was nondiagnostic.

The preoperative laboratory and serological tumor biomarkers, including alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), and carbohydrate antigen 19–9 (CA19-9), were all normal. The baseline hematologic and coagulation parameters were unremarkable.

After reviewing the angiographic phase of the CT scan, we estimated that we could save more than 50% of the spleen with the blood supply. We decided to perform LPS with temporary clamping of the splenic trunk for the removal of the lower splenic pedicle.

3. Surgical Techniques: (See Supplementary Video S1)

The patient was placed on aright semi lateral decubitus position with separation of the patient’s leg as in the French position. The operating table was set in the head-up position, and the surgeon stood between the patient’s lower extremities. After creation of a pneumoperitoneum to a pressure level of 14 mmHg, four ports were placed as follows: a 10 mm port was placed at the umbilicus for the scope, and another three trocars were placed underneath the left costal cage (two of 5 mm and one of 12 mm). A meticulous inspection of the abdominal cavity was conducted to ensure that no malignant tumors were present. A four-step approach was then selected in order to perform the procedure.

Mobilization: The lesser sac was entered, and the short gastric vessels were dissected with an ultrasonic scalpel; then, the splenic flexure of the left colon was mobilized.

• Occlusion of the splenic artery and vascular dissection: The peritoneum above the pancreas was opened up, the main splenic vessel was dissected and transiently clamped using a laparoscopic “bulldog” in order to stop the inflow into the spleen, laparoscopic ultrasound Doppler was performed in order to make sure that there is no arterial inflow to the spleen. A well-defined future resection line was delineated by electrocautery.
• Splenic tissue division: While the principal lienal vessel was continuously compressed (warm ischemia), dissection was performed along the demarcated line using an ultrasonic scalpel and a laparoscopic bipolar device. Once the dissection was finished, the cutting edge was inspected for bleeding; in such a case, it was controlled using bipolar and collagen patch (Ethicon Inc., Raritan, NJ, USA).
• Excised tissue extraction: The specimen was placed into the bag and extracted from the site of the 12 mm port after dilatation of the trocar incision. The spleen was not morcellated or destroyed because of the unknown nature of the tumor. Then, the operative field was irrigated, the drain was left, and the peritoneal gas was expelled, followed by access site closure.

The surgery length was about 105 min, it took about 48 min from placement of the bulldog on the splenic artery, transecting the splenic parenchyma and release of the bulldog. The intraoperative blood loss did not exceed 50 mL. Immediately after releasing the bulldog, the remnant spleen regained its normal color, which reflects normal perfusion.

The postoperative period was without complication, and on the third day after the surgery, the patient was sent home.

The final pathology showed sclerosing angiomatoid nodular transformation. The mass shows nodular architecture separated by fibrotic collagenous tissue, with the nodules’ proliferation of small blood vessels (CD34, CD31, and CD8 without numerous dendritic cells and macrophages (CD68). This feature is most consistent with sclerosing angiomatoid nodular transformation of the spleen presenting as a mass. No malignancy was seen.

4. Discussion

Total splenectomy (TS) carries the risk of several complications, including portal vein thrombosis, elevation of the platelet count, elevated pulmonary pressure, increased blood loss, pancreatic fistula, thromboembolism, bleeding, and intrabdominal abscess. In addition, one of the most serious and fatal complications after TS is overwhelming post-splenectomy infection (OPSI) with a reported prevalence of 4% after TS [12,13].

LPS has emerged as an alternative technique in the treatment of many pathological conditions that arise in the spleen. It has the advantage over TS in that it guarantees removal of the pathologic tissue and the simultaneous maintenance of splenic function [14,15].

Christo first published the results of partial splenectomy, followed by a detailed description of this procedure in 1980 by Morgenstern and Shapiro. Then the LPS was performed by Poulin in 1995 [16,17,18].

Previous reports demonstrated that preservation of one-third of splenic tissue adequately contributes to saving the immunological function of the spleen [19].

Based upon the suggestion proposed by the European Association for Endoscopic Surgery (EAES), the resected volume of the spleen should be equal to or less than 50% [20]. Several techniques were used in conjunction with selective or non-selective splenic vessel occlusion, including the use of energy devices and microwave ablation, with promising results confirming their safety [21,22,23,24,25,26].

A study by Yunjie Lu et al. [27]. reported the use of selective closure of the splenic vessels that supply the lesion with successful partial splenectomy performed in 41 cases [27]. While this technique confirms that partial splenectomy is safe, it is still challenging when compared to simple non-selective occlusion of the main splenic artery, as we and others have described [28,29]. Also, angiographic embolization could be considered as an alternative method to improve demarcation; however, this method had disadvantages of additional risk procedure. Table 1 summarizes and compares the main differences between our and others’ recently reported techniques in regard to operative time, blood loss and techniques detailed.

Table 1. The difference of our technique as compared to others reported techniques.

Article	Year	Technique	Bleeding Amount, Milliliter	Operation Time, Minutes	Number of Cases	Pathology
Wang X. et al. [14]	2014	Selective occlusion of splenic vessels	100–400	148	11	Benign lesions
Lee SH. et al. [11]	2015	Selective occlusion of splenic vessels	422.6 ± 187.4	168.6 ± 46.8	7	Epithelial cysts, Hemangiomas, Lymphangiomas, Abscesses, Metastatic tumors, and Hamartomas
Romboli A. et al. [23]	2021	Selective occlusion of splenic vessels	Not reported	128  ±  43.7	457	Benign tumors
Cai L. et al. [22]	2022	Selective occlusion of splenic vessels	100	120	1	Benign tumors
Fedele S. et al. [25]	2022	Selective closure of splenic branches followed by parenchymal resection. Temporary clamping of main trunk of splenic A. was required only once.	135.7 ± 103.6	75–140	7	Benign tumors
Lu Y. et al. [27]	2022	Selective ligation of splenic vessels suppling the lesion.	108.8 ± 207.6	130 ± 38.4	26	Benign tumors
Xing D. et al. [29]	2023	Separating Tissues around the splenic hilum to expose the 2ry branches of the splenic A. followed by closing the main trunk of the splenic A. with vascular clamp.	178 ± 70	120 ± 17	22	Benign tumors
Lin J. et al. [26]	2024	Occlusion of main splenic trunk with vascular loop followed by dissection and ligation of vascular branches of upper or lower pole of spleen.	93.00 ± 58.4	162.25 ± 37.96	20	Benign tumors
Zhou Z. et al. [28]	2024	1st they Perform temporary occlusion of the splenic artery followed by temporary occlusion of the splenic artery branches at the hilum.	30	102	1	Benign tumors
Ye T. et al. [8]	2025	Selective occlusion of splenic vessels	50	145	1	Benign lesion
Wang X. et al. [7]	2025	Three block technique (main artery occlusion + pedicle occlusion + parenchymal occlusion)	50–100	167.33 ± 59.08	18	Benign lesion
Khalayleh H, et al.	2026	Main splenic artery occlusion.	50	Total 105. Resection time just 48 min	1	Benign lesion

The time of warm ischemia was within the safe margin as defined by Teperman SH. et al. [30]. Two hours of splenic ischemia appears to be safe for dogs; consequently, one hour of warm ischemia for humans was defined as sufficient for most procedures that involved splenic tissue resection [30].

In our case, it took about 48 min from the placement of the bulldog on the splenic artery, transecting the splenic parenchyma and release of the bulldog. This time frame was within the acceptable time limit suggested to be safe by Teperman SH et al. [30].

The operative time altogether was about 105 min, blood loss during the procedure was negligible and did not exceed 50 mL, which is comparable to or lower than the blood loss of other studies. Therefore, the advantages of transient clamping of the trunk of the splenic artery include reduced splenic parenchymal bleeding, shorter operative time due to reduced time required for hemostasis, and a decreased need for blood transfusion, and, as a consequence, possible conversion to open surgery.

5. Conclusions

LPS is an effective spleen-preserving surgery. There are many effective bleeding control methods; in our case, we performed LPS by temporary compression of the principal trunk of the splenic artery. It is worth noting that this technique looks simple and easy to acquire if compared to other reported complex techniques. The simplicity of our technique is derived from the elimination of the need for dissection beyond the main splenic artery, which makes these techniques attractive and easy for adoption. The outcomes as well as the efficacy of this procedure are more than acceptable by any measure. However, many other cases and reports are needed to confirm these findings.